Best practices for endoscopic ultrasound–guided gastroenterostomy: technical recommendations from an international modified Delphi process

Background and Aims EUS-guided gastroenterostomy (EUS-GE) increasingly has been adopted for gastric outlet obstruction, yet significant technical variability exists, which might account for heterogeneous clinical outcomes. The aim of this initiative was to gather expert consensus on key aspects and open questions of EUS-GE. Methods A total of 25 international leading experts in EUS-GE participated in a modified Delphi process over 3 rounds, involving anonymous voting on 35 predefined statements, using a 5-point Likert scale. Statements were approved, revised, or discarded on the basis of predefined median [IQR] thresholds; for approved statements, the strength of the agreement was determined by the proportion of responses rated 4 or 5. Results rate was 88% in round 1 and 100% in rounds 2 to 3. Thirty-one statements were approved, whereas 4 were ultimately rejected. Early and very strong agreement (>95%) was reached on the need for fluoroscopy, free-hand release of electrocautery-enhanced lumen-apposing metal stent, and need for competence in managing perforations, bleedings, dysfunctions, and (after more extensive discussion) misdeployments. Final strong agreement (>90%) was reached on sedation regimen, preferred patient positioning, and saline as distending solution. Extensive discussion with final moderate agreement (>80%) was reached on the use of dye, the preference for catheter-assisted EUS-GE instead of endoscope- or needle-directed instillation, the typical location for EUS-GE, and the operative space required for lumen-apposing metal stent release. Statements on the use of contrast and the choice between specific techniques were removed because of a lack of agreement. Conclusions Despite technical differences (such as the preference of a jejunal catheter or a double-balloon catheter), most experts in EUS-GE agree on key technical principles, providing valuable guidance on the standardization of EUS-GE in clinical practice. Conversely, certain topics show limited agreement, identifying future research priorities in the field of EUS-GE.